THE AFFORDABLE CARE ACT IN CALIFORNIA: After Two Years - Big Benefits, More Work to Do pdf

1
THE AFFORDABLE CARE ACT IN CALIFORNIA
After Two Years - Big Benefits, More Work to Do
This 2012 report marks the second anniversary of the federal health reform law,
and highlights the work that has been done in California, the benefits that
Californians are already enjoying, and the outstanding issues that need to be
addressed. Each section of the report looks at the Affordable Care Act from the per-
spective of one key California constituency. The appendix section also includes a sec-
tion that highlights the personal stories of Californians who have benefited from
health reform.
M
ARCH 2012
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Californians with Pre-Existing Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Uninsured Californians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Californians with Private Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
California Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
California Communities of Color . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
California Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
California Seniors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
California Small Businesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Appendix I: Individual Stories from Californians . . . . . . . . . . . . . . . . . . . . . . . . . .26
Appendix II: California Legislation Enacted 2010-11 . . . . . . . . . . . . . . . . . . . . . . .29
Appendix III: Implementing and Improving Health Reform – 2012 Legislation .
32
2
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
SUMMARY
Two years ago, on March 23, 2010, President Barack Obama signed into law the
Patient Protection and Affordable Care Act (ACA), a historic comprehensive feder-
al health care law. The passage of the ACA was the culmination of decades of move-

ment toward health reform as well as a grueling two-year political process. The law
includes the biggest reforms of our era in three areas:
• Providing new consumer protections to prevent the worst insurance industry
abuses.
• Ensuring affordability and security for those with coverage, and new and afford-
able options for those without coverage, including the biggest expansion of
coverage since creating Medicare.
• Helping control health care costs, improve quality, and encourage prevention
and wellness.
The law offers a mix of immediate relief, put in place in the first year to assist
Americans suffering from some of the worst problems with the health care system,
and a phased-in implementation scheduled for the remaining provisions, with full
impacts starting in 2014.
Just two years after the passage of the federal Affordable Care Act, hundreds of
thousands of Californians are taking advantage of new coverage and care options,
and millions are benefitting from new consumer protections and help affording health
care. These new rights, options, and benefits are not just the result of the ACA, but
also California’s proactive efforts to take advantage of new resources and benefits for
the state’s beleaguered health system.
Having attempted comprehensive health care reform many times as a state, California
was quick to recognize the opportunity offered by the ACA. Immediately after the law
passed in 2010, California went to work implementing the law with the adoption of a
“bridge to reform” Medicaid waiver agreement with the federal government, and the
passage of several bills to implement and improve upon parts of the law. Nationally,
California has been one of the national leaders in implementation, but there is much
more for the state to do to maximize the benefits and improve the health system.
Effective implementation will mean millions more Californians will gain more security
and confidence in their coverage, stemming from the new consumer protections and
increased insurance oversight in place. Millions more will get added help in affording
and accessing coverage as California continues its implementation of the federal law

in the next several years.
The implementation and improvement efforts underway in the last two years have
been fast and furious. Some highlights include:
• Passing landmark legislation: California started passing health reform imple-
mentation legislation in the 2010 legislative session, and has since passed laws
creating a new state based exchange, codifying a number of key consumer pro-
tections into state law, and allowing for the expansion of coverage options.
Additionally, new California laws put into place new regulation and oversight of
insurers.
• Creating new programs and entities: The first in the nation (post-reform)
Health Benefits Exchange was created in California; as well as PCIP, an insurance
option for individuals with pre-existing conditions; and a unique federal-state-
local partnership called the Low Income Health Program made possible by the
1115 Medicaid Waiver.
• Securing federal funding for reform: The state has taken advantage of new
funding opportunities from the federal government including $40,421,383 to
fund the creation and operation of the Exchange; $210,100,000 to improve the
community clinic safety net; $5,300,000 to review unreasonable insurance rate
increases; and $85,500,000 to improve public health.
• Regulatory advocacy: The state, with the input of consumers, has weighed in
on a number of federal rules and regulations related to the implementation of
the ACA, and worked to ensure that federal guidelines meet the diverse needs
of California.
Real Californians are beginning to reap the benefits of this work:
• Individuals with pre-existing conditions have new access to coverage with over
8,600 Californians getting coverage in a new Pre-existing Condition Insurance
Program (PCIP), and the implementation of a new state law to ensure that chil-
dren have access to private coverage regardless of health status.
• Over 370,000 low-income Californians are now covered through Low Income
Health Programs (LIHPs) in 47 counties, and potentially over a half-million will

get coverage in the next two years, prior to 2014.
• 355,927 young adults in California avoided becoming uninsured when the ACA
allowed them to remain on their parents’ coverage.
• 6,181,000 Californians had their coverage improved to include preventative care
without cost-sharing.
• 8,978,000 insured Californians gained new consumer protections, including
Medical Loss Ratio requirements that give consumers more value for their premi-
um dollars.
3
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
4
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
• California consumers saved over $100 million dollars in savings from rate hikes
that were retracted, rolled back, or withdrawn as a result of rate review.
• 319,429 California seniors saved $171,983,735 in prescription drug costs.
• Over 12 million Californians no longer have a lifetime limit on their health insur-
ance plan.
However, a tremendous amount of work remains in order resolve issues not
addressed by the ACA, and to ensure that all Californians have access to quality
and affordable health care. Some of these issues include:
• Putting in place the new options and consumer protections so California is ready
in late 2014—from the Medi-Cal expansion to the insurance market reforms.
• Improving access to care and coverage through key systems reforms. This
includes a streamlined eligibility and enrollment system and consumer
assistance center.
• Maximizing enrollment on day one will ensure that all eligible individuals get
into coverage from the moment it is available, and that the state maximizes fed-
eral dollars.
• Striving toward health equity and the elimination of disparities between
communities.

This report was prepared by Linda Leu, health care policy analyst at Health Access, a
statewide coalition of consumer, community, ethnic, senior, labor, faith, and other organi-
zations that has been dedicated to achieving quality, affordable health care for all
Californians for over 20 years.
To follow up, contact Linda Leu at
or Anthony Wright, executive director, at
Please visit our website at www.health-access.org and read our daily blog at
blog.health-access.org. More materials, including the most up-to-date version of this
report are available there.
Health Access is also on Twitter (www.twitter.com/healthaccess), and Facebook
(www.facebook.com/healthaccess).
5
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIANS WITH PRE-EXISTING CONDITIONS
People who are living with diseases such as cancer often must fight more than their ill-
ness. Individuals with “pre-existing conditions” such as cancer, heart disease, diabetes,
etc. have been shut out of the health insurance market—either denied coverage,
charged exorbitant premiums, or left with coverage that excludes benefits for their
health conditions. The result has been thousands of individuals with serious health
conditions who are uninsured—unable to afford health insurance or pay out of pocket
for their own medical care. They delay or forego needed care, or go deeply into debt
to pay for treatment. It's a situation that puts lives at risk.
PROBLEM
The uninsured are more likely to be diagnosed with cancer at later stages, and are less
likely to survive the disease
1
. Approximately 6,487,000 California adults under age 65
and 576,500 children under age 18 have pre-existing conditions
2

. More than 300,000
people in this country die from cancer each year because they lack access to appropri-
ate care and treatment. In California, it is estimated that 144,800 people will be diag-
nosed with cancer this year and 55,415 will die from the disease
3
.
SOLUTIONS
In the two years since its passage, the Affordable Care Act has transformed the outlook
for thousands of cancer patients and others with pre-existing conditions, taking them
from "uninsurable" to enrolled, and providing newfound hope and health security.
Because of the ACA, uninsured patients with pre-existing conditions now have access
to affordable health coverage (Pre-Existing Condition Insurance Program (PCIP) in
California) and the worst insurance industry practices that left patients without viable
options for accessing care are now history.
• PCIP is helping to fill a void in the insurance market for those who have been
uninsured for six months or more, and have a pre-existing condition or have been
denied coverage. It is a temporary federally-funded high risk pool that will con-
tinue until January 1, 2014 when insurers will be prohibited from denying cover-
age or charging them more because of a pre-existing condition. PCIP provides
comprehensive coverage including primary and specialty care, hospital care, pre-
scription drugs, home health and hospice care, skilled nursing care, preventive
health and maternity care. There is no waiting period; health care costs are cov-
ered from the first day that PCIP coverage begins. PCIP enrollees are not
charged a higher premium because of their medical conditions; rates are compa-
rable to those charged for healthy people in the individual insurance market.
However, because premiums are not based on income, they may still be unaf-
fordable for some. PCIP greatly expands the state's capacity for covering "unin-
surable" individuals—the Major Risk Medical Insurance Program (MRMIP), a state-
run program has been providing limited benefits at a higher cost.
6

THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
• Because of the ACA, health plans can no longer impose a lifetime dollar limit on
benefits for patients with cancer and other illnesses; caps can cause the sudden
termination of much needed coverage.
• The ACA puts a stop to the practice of insurers rescinding insurance coverage in
response to a diagnosis such as cancer.
• The ACA prohibits insurers from denying coverage to children because of a pre-
existing condition.
IMMEDIATE IMPACTS
• Over 8,600 previously uninsured Californians are enrolled in the Pre-Existing
Condition Insurance Program as of January 31, 2012
4
.
• Estimated 8,837,000 California adults and 3,255,000 California children are bene-
fitting from the prohibition on lifetime limits on health benefits
5
.
• Approximately 576,500 children under age 18 and 6,487,000 adults under age
65 in California with pre-existing conditions are now protected from being
denied coverage
6
.
MORE WORK TO DO
• California will need to transition people with pre-existing conditions enrolled in
PCIP and MRMIP to plans in the California Health Benefits Exchange in 2014
when insurers will no longer be able to deny coverage for individuals with pre-
existing conditions, or charge them different rates.
• The California Health Benefits Exchange must be implemented and operated so
that it improves access to care for people with chronic diseases by decreasing
cost, increasing competition, and offering consumers the peace of mind that they

are buying a quality health plan.
• Minimum essential benefits must be established to ensure coverage of proven
ways to prevent and treat diseases such as cancer.
• Medi-Cal eligibility must be expanded so that low income people with cancer
can get access to the quality care they need.
1
CA: A Cancer Journal for Clinicians (2007; 110: 395-402 and 403-411)
2
Families USA, "Health Reform: Help for Americans with Pre-existing conditions, May 2010,
/>3
American Cancer Society, California Department of Public Health, California Cancer Registry. California
Cancer Facts and Figures 2012. Oakland, CA: American Cancer Society, California Division, September
2011.
4
MRMIB.
5
ASPE Issue Brief, March 5, 2012
6
Estimates based on pre-existing conditions diagnosed or treated in 2007, prepared by The Lewin Group
for Families USA.
7
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIA’S UNINSURED
While providing more security to those who have coverage, a goal of the Affordable
Care Act (ACA) is also to expand coverage options to millions of Californians, many of
whom were previously uninsured. In addition to providing more coverage options, the
state is actively engaged in efforts to streamline eligibility and enrollment processes in
order to make it easier to access coverage; and to enact protections that will help con-
sumers more easily choose plans based on cost and quality.

PROBLEM
There are 8.2 million uninsured Californians in a given year—and as a result,
Californians live sicker, die younger, and are one emergency away from financial ruin.
Employer-sponsored health insurance dropped from 55.6% in 2007, which was already
among the lowest of all states, to 52.1% in 2009. While 7 million of the lowest-income
Californians are covered under the Medi-Cal program, Medi-Cal’s eligibility criteria
leave many still in need.
SOLUTION
The ACA expands coverage options for those without insurance in two important ways:
• Expanding Medi-Cal to 2 million more Californians: Medi-Cal’s eligibility crite-
ria prior to the ACA excluded many adults without dependent children, no mat-
ter how low their income. Eligibility rules also excluded low-income individuals
based on a restrictive and cumbersome assets test. In 2014, those restrictions will
be removed. Additionally ACA improves Medi-Cal for existing and new enrollees
by funding innovations like medical homes and community health teams, and by
increasing funding to community clinics.
• Creating a California Health Benefits Exchange: The Exchange will help an
additional 2-4 million Californians access coverage through a fair, transparent,
and consumer-friendly marketplace. The Exchange will negotiate on behalf of its
individual consumers, much like large purchasers do now; as well, the Exchange
will offer subsidies to 2.2 million Californians with incomes under 400% of the
Federal Poverty Level, making insurance premiums more affordable.
• Consumer Protections to Keep Consumers Insured: The ACA outlaws a num-
ber of insurance industry practices that have kept individuals uninsured including
medical underwriting, rescissions, and annual and lifetime limits.
IMMEDIATE IMPACTS
Early Expansion of Medi-Cal: California has been granted a special waiver by the fed-
eral government to begin expanding coverage prior to 2014. These Low Income
Health Programs (LIHP) are county-based coverage programs similar to Medi-Cal. LIHP
allows low-income uninsured adults to access quality, comprehensive health coverage

8
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
delivered through a medical home model. In 2014, everyone enrolled in LIHP will be
automatically moved to Medi-Cal. Local LIHPs began enrollment in ten counties in July
2011, and now 47 of California’s 58 counties are enrolling people in LIHP, with over
370,000 enrolled as of January 2012. By 2014, LIHP is expecting to enroll at least
500,000 low-income Californians who will then be able to take advantage of the Medi-
Cal expansion as soon as possible.
Major Young Adult Expansion: Young adults (18-25 year olds) are the most likely age
group to be uninsured—less because of supposed thoughts about “invincibility” and
more because just starting out in their careers, they are more likely to be low-income,
and more likely to work at a job that does not provide coverage. One of the “early”
provisions of the ACA allows young adults up to age 26 to sign up on their parents
coverage. Estimates are that over 355,927
1
young Californians from 18-25 now have
coverage through their parents’ plan—many of whom would have been uninsured
without this new option.
New Access for Those with Pre-Existing Conditions: While most uninsured
Californians are not covered due to affordability issues, many with pre-existing condi-
tions can’t get coverage at any price. For them, the ACA is providing new access to
coverage already, prior to 2014, when insurers will no longer be able to deny or
charge more because of a person’s health status:
• Over 8,600 Californians are no enrolled in the Pre-Existing Condition Insurance
Program, which, for a fair market premium, provides coverage to those denied
for pre-existing conditions.
• Tens of thousands of California children with pre-existing conditions now have
the option of getting private coverage. In the 2010 law AB2244, California went
beyond the ACA’s requirement that insurers must not deny coverage to any
child—both by ensuring that insurers offer “child-only” policies (or lose business

covering adults), and by placing a limit on how much more children with pre-
existing conditions could be charged.
Setting up the California Health Benefits Exchange: Since the signing of California
legislation to create the Exchange in September of 2010, the state has been hard at
work to get the Exchange ready for operation January 1, 2014. The Exchange Board
has moved at a rapid pace, meeting at least once a month since April 2011 to discuss
and make policy decisions related to the operations of the Exchange. In its short exis-
tence the Exchange has secured federal funding to build its operations, made several
important policy decisions, responded to federal regulations in order to provide the
federal government with California perspective, and begun the creation of a world
class IT system, the California Health Eligibility, Enrollment, and Retention System,
which will serve not just the Exchange, but other public programs with a “no wrong
door” approach when it comes into use in 2014.
MORE WORK TO DO
A great deal of work remains to ensure that the Exchange is ready to “open its doors”
on January 1, 2014. The Exchange must complete its system designs, negotiate rates
and contracts with health plans, and reach out to consumers who will qualify for its
services. Consumer advocates must participate in all of this work by offering concrete
suggestions about how to build consumer protections and consumer friendly practices
into new systems and processes.
As we approach 2014, the health care system must also ramp up capacity to prepare
for the millions of Californians who will be newly eligible for coverage. LIHP is
designed to be an integral part of the “bridge to health reform;” aggressive outreach
and enrollment efforts in that program will ensure a smooth transition as well as maxi-
mum enrollment from day one.
Bills in the legislature would implement the Medi-Cal expansion and new eligibility
and enrollment rules. In addition, Health Access is supporting measures to ensure that
as many Californians as possible can enroll in the ACA’s new options as early as possi-
ble—with the goal of covering millions of Californians on day one, January 1, 2014.
AB714 (Atkins) and AB792 (Bonilla) are measures currently being considered by the

legislature which would facilitate early and automatic enrollment.
Additional advocacy must also consider the populations that will be left out of the
ACA, including the undocumented population, and focus on state-based solutions to
provide health coverage to all Californians.
9
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
1
/>10
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIANS WITH PRIVATE INSURANCE
While individuals who are insured have better physical and mental health outcomes,
those with inadequate insurance or who have difficulty accessing the benefits of insur-
ance need more help. Californians who have private health insurance still benefit from
the Affordable Care Act’s provisions that make health insurance more affordable,
accessible, and likely to be there in times of need.
PROBLEMS
The cost of health insurance is a growing burden for consumers. The ever increasing
share of expenses consumers must cover, makes it difficult for those with insurance to
stay out of debt and keep their coverage. From 2007 to 2009 the number of
Californians with medical debt increased by 400,000, and a significant number of these
individuals had insurance. Meanwhile, before the Affordable Care Act, insurers were
allowed to engage in a number of practices that benefited their bottom line more than
the health of their members.
SOLUTIONS
New Consumer Protections
Health insurers are subject to new rules that give patients new protections and apply
to all plans, with few exceptions:
• Insurers can’t impose a lifetime limit on your benefits, meaning you don’t have to
worry about your coverage maxing out when you most need it.

• Annual benefit limits are phasing out too, rising from $750,000 in 2010 to $2 mil-
lion in 2013 before being abolished in 2014. The annual benefit limit for
September 2011 through September 2012 is $1.25 million
3
.
• Health insurers can’t arbitrarily cancel your coverage if you get sick or make a
mistake on your application.
• Insurers are required to provide preventive care such as flu shots, well-baby
checkups, colon cancer screenings, and mammograms with no out-of-pocket
costs
Real Standards for Insurers, Saving Policyholders Real Money
Before the passage of the ACA, almost half of consumers who bought their own insur-
ance were in plans that spent more than 25% of every premium dollar on administra-
tive costs. That changes under the ACA:
• Insurance companies must publicly report how much they spend on health-care
costs and on administrative costs.
11
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
• For plans purchased by a large employer or other large group, your insurer must
spend at least 85% of premiums on medical care, or rebate the difference to you.
• For plans purchased through a small employer or on your own, insurers must
spend at least 80% of premiums on medical care, or give you a rebate.
• Rebates owed on 2011 premiums must be paid by August 2012.
Justifying Rate Increases to Consumers
States are responsible for reviewing health insurance rate increases to ensure they are
justified. California received $5.3 million to crack down on unreasonable insurance rate
increases
4
.
•

Insurers must now publicly post and justify a rate increase, under California law and
implementing the federal Affordable Care Act. California regulators will determine
whether the increase is unreasonable based on health-care costs and other factors.
IMMEDIATE IMPACTS
• Over 12 million California residents with private insurance no longer have
to worry about facing lifetime limits on coverage, because of the Affordable
Care Act
4
.
• The 2.5 million residents of California who buy coverage on the individual
market can now trust that their coverage will not be rescinded due to a mis-
take on an application.
• Due to medical loss ratio rules, it is estimated that insurers may owe consumers
as much as $1.4 billion in rebates or lower rates in 2012 based on the 2010 insur-
ance market
6
. In California alone, medical loss ratio rules may require an esti-
mated $78.49 million to be paid to consumers in rebates
7
.
• Under California’s rate review authority to implement ACA requirements,
California insurance regulators have been able to negotiate reductions in
rate increases saving consumers well over $100 million
8
. For example, regula-
tory action by the Department of Insurance and Commissioner Dave Jones com-
pelled Anthem Blue Cross to reduce their proposed rate increase on 600,000
California policyholders from 16.4 percent to 9.1 percent, saving California indi-
viduals and families a total of at least $40 million
9

.
• Approximately 54 million Americans, including about 6,181,000 Californians,
took advantage of least one new free preventive service in 2011 provided
under the ACA through their private health insurance plans. Additionally,
roughly 32.5 million people with Medicare received free services, including 3 mil-
lion in California
10
.
12
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
MORE WORK TO DO
Though the Affordable Care Act and state law SB1163 (Leno) established the authority
of state regulators to review insurance rate increases, they did not give regulators the
same authority 34 other states have to reject unreasonable rates. AB52 (Feuer) would
establish rate regulation.
Additionally, California continues to push forward legislation to reform the individual
and small group markets to conform with the new regulations under the ACA.
California also continues to look at ways in which we can make health insurance more
affordable to consumers, as well as to improve access to individuals from communities
of color and rural and otherwise disenfranchised communities.
1
Fronstin P. Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2009
Current Population Survey. Employee Benefit Research Institute; 2009. EBRI Issue Brief no. 334.
2
/>3
/>4
Office of the Assistant Secretary for Financial Resources
5
Assistant Secretary for Planning and Evaluation, US DHHS
6

HHS, />7
/>8
/>9
(CDI, />10
(HHS, KPBS />13
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIA WOMEN
The Affordable Care Act (ACA) provides specific benefits to women that help to
address some of the inequalities that exist in the health care system.
PROBLEM
Women experience a number of gender-based barriers to getting basic health care.
• Some insurers have denied coverage to women based on gender specific criteria
such as current or past pregnancy.
• Some insurers have charged women more for the same insurance coverage than
they charge men of similar health status and age.
• Women experience difficulty accessing basic services as many insurers have cum-
bersome referral processes to access obstetric and gynecological care.
• Some women have trouble accessing basic women’s health care such as preven-
tive screenings and maternity care because of high out of pocket costs or
because those services are not covered.
SOLUTIONS
In addition to broader coverage expansions, affordability improvements, and consumer
protections, the ACA includes a number of provisions that specifically address the dis-
crimination faced by women:
• Denials Based on Pre-Existing Conditions: Outlawing denials based on pre-
existing conditions for adults impacts men and women, but in many cases,
women’s pre-existing conditions are directly related to their gender. In 2014,
insurers will be prohibited from denying coverage for these reasons.
• Gender Rating: In 2014 the ACA outlaws gender rating, or the practice of charg-

ing women more for insurance than men based on gender alone.
• Access to Basic Services: The ACA sets guidelines for Essential Health Benefits,
or basic benefits that all health plans must provide – among them are health
services for women such as maternity care. Additionally, the ACA requires that
women be able to choose their own doctor, including an OB-GYN, and that
women have access to OB-GYNs without referrals.
• Preventive Care: The ACA requires insurers provide preventive care, including
important screening and services for women, with no cost-share. Screenings for
breast and cervical cancer, contraception, and many pregnancy related services
are included.
14
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
IMMEDIATE IMPACTS
As a result of the ACA, 1,765,300 California women have accessed free preventive
services through Medicare, and another 2,286,000 California women who have private
insurance have also enjoyed this benefit
1
.
California has worked hard to implement and improve upon the ACA. One key accom-
plishment has been the passage of legislation that requires insurers to cover maternity
care beginning in 2012 instead of 2014 as the federal law requires. Fewer and fewer
insurers—only 12% in the individual market—provided maternity benefits, creating a
tremendous burden on women and families and a significant cost shift to public pro-
grams. SB222 and AB210 signed into law in 2011 are important steps in reversing that
dangerous trend.
MORE WORK TO DO
The ACA has been used as an opportunity for opponents of women’s rights to try to
restrict choice and restrict access to a comprehensive range of reproductive health
options. This debate continues to play out over coverage of abortion and contracep-
tion. As federal lawmakers and a handful of other states attempt to take away women’s

access to health care, it is crucial that California continue to provide state funding to
ensure access in our state.
1
/>CALIFORNIA
WOMEN’S
AGENDA
15
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIA COMMUNTIES OF COLOR
PROBLEM
In California, communities of color comprise close to three-quarters of the uninsured.
Lack of health care coverage can lead to delays in medical services, mounting medical
debt and bankruptcy, increased suffering, and the premature onset of chronic disease
and death. Increasing racial and ethnic health disparities show the consequences of
millions lacking access to coverage.
SOLUTION
Two years after the signing of the Patient Protection and Affordable Care Act (ACA),
the law has already helped thousands of low-income Californians of color get the care
they need.
IMMEDIATE IMPACTS
• One in five adults now enrolled in California’s Pre-Existing Condition Insurance
Program (PCIP) is a person of color.
• In California, adolescents of color are more likely than their white counterparts to
be uninsured. Thanks to the ACA, over 355,000 more young adults between
the age of 19 and 26 are insured, many of them adolescents of color, thanks to
a provision that allows them to stay on their parent’s insurance plan.
• Communities of color comprise roughly 80% of uninsured Californians living
below 200% of the Federal Poverty Level. These individuals are eligible to
receive basic health care services through Low Income Health Programs

(LIHPs). As of January 2012, California had enrolled more than 370,000 individu-
als into LIHP, many of whom will be eligible for Medi-Cal in 2014.
• Nearly 1 million Californians received expanded preventive benefits coverage
in 2011. Coverage for these services help bring down health care costs for the
state while significantly reducing health disparities in communities of color. For
example, people of color represent over half (51.5%) of the state’s approximately
3.9 million smokers, so tobacco cessation programs would be a tremendous ben-
efit to these communities.
• The law includes stronger requirements for the collection of data on race,
ethnicity, and primary language. Enhancing data collection will have a dramatic
impact on our ability to develop culturally appropriate programs and target inter-
ventions to the communities in greatest need. For example, within the Asian and
Pacific Islander community, there are many different ethnic groups, and dispari-
ties between and even within these groups that can be overlooked if they are all
classified under the same category.
16
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
MOVING FORWARD
California is moving forward with the creation of the Health Benefit Exchange, which
will put affordable health care coverage within reach of millions of Californians.
Communities of color will benefit greatly from the ACA, representing 67 percent of
those qualifying for subsidies in the Health Benefits Exchange and 72 percent of the
adults newly eligible for Medi-Cal
1
. A significant portion of the newly eligible (40 per-
cent in the Exchange and 36 percent in Medi-Cal) will be Limited English Proficient
(LEP). In order to fulfill the promise of the ACA, California must:
• Target resources for consumer assistance to those with the highest needs.
We must provide the newly eligible with the information they will need to navi-
gate the Health Benefit Exchange. Online information should be made available,

at a minimum, in the 13 current Medi-Cal Managed Care threshold languages
2
.
With so many ways to apply for health coverage—online, by phone, by mail, or in
person—it will be especially important for the state to target resources for in-per-
son assistance to communities with the highest needs, including low-income pop-
ulations, immigrants, the Limited English Proficient, and persons with disabilities.
• Invest in culturally and linguistically appropriate marketing and outreach.
Research shows that communities of color are less likely to know about the ACA,
but are very enthusiastic when they are the intended audience for outreach
efforts
3
. With limited resources, the state will have to carefully target funds for
marketing and outreach efforts to reach the communities that constitute a majori-
ty of those eligible to receive subsidies in the Exchange. We must also make sure
there is consumer confidence in insurance products sold after 2014. SB1313
(Lieu) and AB1761 (Perez) will help to protect consumers by making it illegal to
make misrepresentations about the requirements under the ACA, requiring
health plans that advertise in non-English languages to meet existing language
access requirements, and prohibiting an individual or entity from holding oneself
out as representing the Exchange without a valid agreement with the Exchange.
• Strengthen data collection efforts to help identify and address disparities.
The ACA requires states to adopt new federal standards for collecting data on
race, ethnicity, and primary language, and to report on the progress made toward
eliminating health disparities
4
. This is a good first step; however, the tremendous
diversity of our state necessitates adopting the additional data categories for
California’s subpopulations, as recommended by the Institute of Medicine (IOM)
and encouraged by the Office of Management and Budget (OMB), as these cate-

gories will more accurately represent California’s demographics and allow the
state to better target interventions to address health disparities
5
.
• Invest in primary care and workforce diversity in underserved areas. The
ACA provides funds to enhance workforce diversity and increase access to quality
care in underserved areas. California must protect federal funds to increase work-
force diversity, make the temporary Medi-Cal provider rate increases in 2013 and
17
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
2014 permanent, and work with the Health Benefit Exchange to strengthen
health care quality by requiring health plans to demonstrate their capacity to
offer culturally and linguistically appropriate services, particularly in underserved
areas, as well as to develop a plan to identify and address disparities in utiliza-
tion, access, and health outcomes among their diverse members.
• Ensure collaboration between state and local government agencies and
providers across public programs to maximize enrollment. The successful
transition from the current system with multiple application processes for publicly
funded programs to be a seamless “no wrong door” system will depend on a
strong collaboration between the state, counties, and providers. Eligible individu-
als in publicly funded programs, as well as those who may be losing health cov-
erage due to life transitions (e.g., job transition or divorce), should be identified,
and fast, confidential, and effective transition methods developed to ensure time-
ly enrollment using methods such as pre- and auto-enrollment. The legislature is
considering a number of measures that would require this: AB714 (Atkins),
AB792 (Bonilla), and SB970 (De Leon).
• Promote prevention and wellness. The ACA originally allocated $15 billion for
the federal Prevention and Public Health Trust Fund to transform our health care
system into one that invests in keeping people well, not just in treating the sick.
Political opponents have repeatedly attacked and diminished this funding.

California should take the lead in promoting health and wellness by ensuring that
funds for Community Transformation Grants are disbursed to populations with
the highest need, and that California’s Health Benefit Exchange uses its market
role to fulfill its mission of transforming our health care system into a system that
promotes prevention and wellness.
1
“Daphna Gans, Christina Kinane, Greg Watson, Dylan H. Roby, Jack Needleman, Dave Graham-Squire,
Gerald F. Kominski, Ken Jacobs, David Dexter, Ellen Wu, “Achieving Equity by Building a Bridge from
Eligible to Enrolled,” February 29, 2012.
2
The 13 threshold languages for Medi-Cal Managed Care are Arabic, Armenian, Cambodian, Cantonese,
English, Farsi, Hmong, Korean, Mandarin, Russian, Spanish, Tagalog, and Vietnamese.
3
Field Research Corporation. Majorities of Californians Support the Nation’s New Health Care Law, But
Think More Health Care System Changes Are Needed. Just One in Three Believes the Law Should Be
Reversed.
4
Section 4302: Understanding Health Disparities: Data Collection and Analysis. Patient Protection and
Affordable Care Act. H.R. 3950, 111th Congress, March 23, 2010.
18
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIA CHILDREN
Children with health coverage and access to health care grow up healthy and ready to
learn, and the health of California’s kids got a major boost when the federal health
reform law, the Affordable Care Act (ACA) was signed two years ago. The ACA is
already helping millions of California children, and even more will benefit once the law
is fully implemented in 2014.
PROBLEM
While California made real progress over the past decade to cover uninsured kids

through Medi-Cal and Healthy Families, nearly 1.1 million California children were
uninsured in 2009, before the Affordable Care Act was signed
1
. In addition, in the
past, because health insurers could limit or deny coverage to children, children often
went without needed health services and care. As a result, millions of California chil-
dren had to delay or forgo preventive care and treatment due to cost or insurance
limitations.
SOLUTION
The ACA strengthens health coverage and access to health care for millions of
California’s children and young adults. The ACA ensures that California children have
better access to quality, affordable coverage that cannot be taken away when they
need it most.
The Affordable Care Act:
• Protects and strengthens Medi-Cal and Healthy Families coverage for
California children. The ACA provides additional federal funding for Healthy
Families and increases Medi-Cal payment rates to health care providers to
ensure low-income children have better access to primary care. The ACA also
protects the 4.5 million low-income California children who currently have Medi-
Cal or Healthy Families coverage by preventing eligibility rollbacks or significant
premium increases.
• Prevents insurance companies from unjustly denying coverage to children.
The ACA bans health insurers from denying coverage to children with pre-exist-
ing conditions and prohibits insurance companies from placing restrictive annual
or lifetime caps on coverage and from rescinding coverage when a person
becomes sick.
• Invests in prevention and provides no-cost preventative care for children.
Pediatric well-child and preventive services are now covered for children with no
co-pays in all public and private insurance. The ACA also provides additional
19

THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
funding for school-based health centers, expansions of local early childhood
home visitation programs, and many other initiatives to promote wellness and
disease prevention in California.
• Expands health coverage of young adults. Under the ACA, young adults are
now able to remain on coverage as dependents through their parents’ employer-
sponsored insurance until they turn 26.
• Makes health coverage more affordable for parents and children. Starting in
2014, families with incomes below 400 percent of the federal poverty line that
are not insured through an employer will be eligible for premium tax credits and
cost-sharing protections to help them purchase health coverage through the
California Health Benefit Exchange, a new marketplace where Californians will
be able to purchase affordable private health coverage.
• Makes it easier to shop for and enroll in health insurance. California agencies
are currently developing an easily accessible online portal where families will be
able to apply for, compare, and enroll in the coverage options that fit their indi-
vidual needs. The ACA will also establish health insurance “navigators,” who will
help families understand and enroll in the best health coverage options.
IMMEDIATE IMPACTS
Millions of California children are already benefiting from the ACA. According to
research-based estimates:
• 1,638,000 California children are receiving expanded coverage of preventive
services without co-pays
2
.
• 355,927 California young adults under age 26 have gained coverage by being
able to remain on their parents’ plan
3
.
• 3,255,000 California children no longer face lifetime limits on health benefits

4
.
• 576,500 California children with pre-existing conditions and their families no
longer have to worry about being denied coverage
5
.
MORE WORK TO DO
California must continue to leverage the opportunities presented by the ACA to
ensure that all children have access to comprehensive, affordable health care. In par-
ticular, California policymakers, stakeholders, and advocates must continue to work
together to develop a strong Exchange that can serve the needs of California chil-
dren, ensure a comprehensive package of Essential Health Benefits for children, and
implement an outreach and enrollment system that makes it easy for families and chil-
dren to enroll in the health coverage that fits their needs. California also must protect
20
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
and strengthen existing children’s coverage programs like Medi-Cal and Healthy
Families to ensure that the upcoming ACA reforms build on a strong foundation.
Particularly important will be support for outreach efforts to enroll the nearly 700,000
uninsured children who are eligible for Medi-Cal or Healthy Families now but are not
enrolled.
This factsheet was prepared by the 100% Campaign, a collaborative effort of The Children’s Partnership,
Children Now, and Children’s Defense-Fund California, in partnership with Health Access.
1
Analysis of 2009 California Health Interview Survey.
2
“Affordable Care Act extended free preventive services to 54 million Americans with private health
insurance in 2011,” U.S. Department of Health and Human Services (February 15, 2012), available at
/>3
“New Data: The Affordable Care Ace in Your State,” The White House (March 5,2012), available at

/>4
“Under The Affordable Care Act, 105 Million Americans No Longer Face Lifetime Limits on Health
Benefits,” U.S. Department of Health and Human Services (March 5, 2012), available at
/>5
“Health Reform: Help for Americans with Pre-existing Conditions,” Families USA (May 2010), available
at
/>21
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIA SENIORS
Since the introduction of the Affordable Care Act (ACA), many misconceptions about how
the law impacts seniors have permeated public consciousness. However, two years after
the law’s passage, it is clear that California Seniors are benefiting from its provisions.
PROBLEM
Though 4.8 million seniors in California receive health coverage through the Medicare
program, seniors yet to turn 65 still struggle to access health care. Some seniors covered
by Medicare also struggle with out of pocket costs, particularly for prescription drugs.
SOLUTIONS
Since implementation of the ACA, California seniors have seen significant savings and
health care improvements from some of the provisions which have already taken effect.
• Closing the Donut Hole: Medicare enrollees can expect to see their prescrip-
tion drug costs decrease; savings are projected to average $4,200 per person
over the first ten years. For hundreds of thousands of elderly people, the days of
choosing between food and medicine are finally coming to an end.
• Medicare Advantage: The ACA included provisions to reform the Medicare
Advantage payment system, which will ensure that seniors can still get high qual-
ity health care while protecting the financial solvency of the Medicare system.
• Long Term Care: An important area for those who need long term care – and
for California taxpayers – is the Community First Choice Option program created
by the ACA. The program has saved people who need homecare from experi-

encing significant cuts in service by making nearly $200 million available to
California to help fund the program. It protects services to seniors and saves
California taxpayers money.
• Reinsurance for Retirees: Another area of assistance is for younger seniors,
those under age 65, who have pre-existing medical conditions and have lost
health care coverage. Thanks to the ACA, California received (or will receive)
funds to implement a new program of individual coverage aimed at this group,
with subsidies to help reduce the extremely high costs these seniors face in the
private market.
• Program Integration: The ACA authorized the creation of a new federal office
to work on better integration of state and federal health programs for seniors
and people with disabilities. California is one of fifteen states that have been
funded to redesign programs that will provide coordinated and integrated care
for medical, mental health, and long term care services. The plan is expected to
greatly improve the quality of health care for 1.2 million mostly older
Californians, and save tax dollars as well.
22
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
IMMEDIATE IMPACTS
•
To date, 319,429 California Medicare enrollees have saved $171,984,000 in out of
pocket costs for life saving prescriptions. The savings averaged $604 per person
1
.
• On average in California, Medicare Advantage insurance premiums have
dropped seven percent in the last year and a total of sixteen percent since the
health reform law took effect.
• Approximately 4.8 million California seniors enrolled in Medicare have access to
preventive services like mammograms and colonoscopies as well as annual well-
ness visits with no out of pocket cost.

• There are 522 employers in California enrolled in the Early Retiree Reinsurance
Program. These employers have been reimbursed over $200 million to insure
seniors not yet eligible for Medicare.
MORE WORK TO DO
Insurance market reforms in the individual market are particularly relevant to younger
seniors who are not yet eligible for Medicare. State legislation implementing provi-
sions of the ACA including limits on Age Rating (charging seniors more for health care
based on age alone) as well as protections for people with chronic or pre-existing con-
ditions must also be enacted to ensure that seniors can access affordable health care.
Also, over the next 20 years the ACA will slow Medicare spending by reducing waste,
fraud, and abuse. These fraud prevention measures and other savings are expected to
extend the solvency of the Medicare program by 12 years. As a result of these
improvements, seniors will likely save an average of $200 in premiums and $200 in co-
insurance costs per year.
1
/>23
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
HOW THE AFFORDABLE CARE ACT BENEFITS
CALIFORNIA SMALL BUSINESSES
California is home to over 180,000 ethnic small businesses
1
, and small businesses in
California employ 5.3 million workers
2
. In addition, 1.9 million Californians are self-
employed
3
. While this means many opportunities for creativity and enterprise, it also
means that millions of Californians are faced with the challenge of purchasing health
coverage in a market that does not favor individuals or small business.

PROBLEM/CONTEXT
Affordability of Health Benefits: Tax Credits available for Small Businesses
Historically, small business owners, especially those with fewer than 25 employees,
pay 18% more than larger firms for the same health coverage
4
. With the implementa-
tion of the ACA, if a small business owner qualifies, they can receive up to 35% in tax
credits. Due to this now available tax credit, fifteen percent of non-offering small firms
(3-49 employees) have considered providing health insurance
5
. The availability of the
tax credit has the potential to allow for more people to have access to employer
based insurance, specifically small business employees.
SOLUTIONS
Benefits from ACA
The tax credit under the ACA is available to small employers with less than 25 full-
time employees, average employee salaries less than $50,000, and who pay at least
50% of the health insurance premium per employee
6
. If an employer qualifies, they
can receive up to a maximum 35% tax credit, 25% for tax exempt firms, depending on
size and average salaries of employees. In 2014, these tax credits increase to 50%,
35% for tax exempt firms, if the employer provides at least 50% of the premium cost
and purchases in the Small Business Health Options Program (SHOP)
7
. As the business
gets larger, and/or average employee wages increase, the credit decreases
8
.
IMMEDIATE IMPACTS

Small businesses have begun to reap the benefits of the tax credits that the ACA pro-
vides. As of mid-May 2011, $278 million in tax credits had been claimed for tax year
2010
10
. As more small business owners are informed of the tax credits, this has the
potential to increase. Fifteen percent of non-offering small firms (3-49 employees) have
considered providing health insurance due to the tax credit available under the ACA
11
.
24
THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
MORE WORK TO DO
California moving towards implementation
California has been spearheading various efforts to implement the ACA. Currently,
California defines small group as having 2-50 employees. Proposed legislation intro-
duced in 2011, AB1083 (Monning), would bring California in compliance with the ACA.
AB1083 would allow self-employed individuals (and businesses with up to 50 employ-
ees) to be defined as small employers beginning on or after January 1, 2014, and
increasing the definition to include up to 100 employees on January 1, 2016. California
is home to over 1.9 self-employed individuals who would benefit by AB 1083
9
. This bill
is currently pending in the legislature.
Adopting President Obama’s Proposed Fiscal Year 2013 Budget
President Obama has called for an expansion and simplification of the Small Business
Health Care Tax Credit. Under this expansion, he has proposed to allow businesses
with up to 50 workers to qualify for the credit, currently only employers with up to 25
full time equivalent workers qualify. If this is adopted, more small businesses will quali-
fy for the tax credit than the initially estimated 4 million.
Ensuring all have access to the tax credit

The IRS mailed approximately 4.4 million postcards to businesses that could benefit
from the tax credit
12
. However, knowledge of the tax credit is still limited among the
small business community. In order to ensure all owners have the opportunity to
receive the tax credit, the application process should be simplified, and a robust out-
reach and education campaign needs to consider the cultural and linguistic needs of
small business owners. This includes utilizing trusted resources in the community to
conduct outreach and education, such as community organizations, small business
chambers, agents and brokers, and the media.
1
U.S. Census Bureau. (2007). Survey of Business Owners (2007). Retrieved from
on September 13, 2011.
2
UC Berkeley Center for Labor Research and Education, “Federal Health Reform: Impact on California
Small Businesses, Their Employees and the Self-Employed (June, 2010).
/>3
U.S. Census Bureau. (2010). Profile of California, Sex by class of worker for the civilian employed popu-
lations 16 years and over. Retrieved March 7, 2012, from
/>0&prodType=table
.
4
“Health Policy Brief: Small Business Tax Credits,” Health Affairs, January 14, 2011.
5
The Kaiser Family Foundation and Health Research & Educational Trust (2011). Employer Health
Benefits 2011 Annual Survey. Henry J. Kaiser Family Foundation. Retrieved from
on March 3, 2012.
6
accessed March 5, 2011.
25

THE AFFORDABLE CARE ACT IN CALIFORNIA After Two Years - Big Benefits, More Work to Do
7
Arax, A. & Martinez, R. (2011). Affording Health Care: Tax Credits in the Affordable Care Act
B
enefitting Your Small Business. The Greenlining Institute.
8
Ibid.
9
U.S. Census Bureau. (2010). Profile of California, Sex by class of worker for the civilian employed popu-
lations 16 years and over. Retrieved March 7, 2012, from
/>0&prodType=table
.
10
T
reasury Inspector General for Tax Administration (2011). Affordable Care Act: Efforts to Implement the
Small Business Health Care Tax Credit Were Mostly Successful, but Some Improvements Are Needed.
Washington: Government Printing Office, 2011.
11
The Kaiser Family Foundation and Health Research & Educational Trust (2011). Employer Health
Benefits 2011 Annual Survey. Henry J. Kaiser Family Foundation. Retrieved from
on March 3, 2012.
1
2
Treasury Inspector General for Tax Administration (2011). Affordable Care Act: Efforts to Implement the
Small Business Health Care Tax Credit Were Mostly Successful, but Some Improvements Are Needed.
Washington: Government Printing Office, 2011.